Illinois Data-Driven Health & Justice Webinar Series

1. Illinois Data-Driven Health & Justice Webinar Series Trauma-Informed Care and Crisis Intervention Teams (CIT) Wednesday, May 24, 2017 www.icjia.state.il.us/ddhj

2. Agenda • Learning Objectives • Presentation on Trauma-Informed Care • Local example: Lake County’s CIT program • Questions & Answers

3. Learning Objectives • Understand the impact of trauma on behavior and health outcomes • Recognize the effectiveness of trauma-informed care • Hear how law enforcement can apply Crisis Intervention Team training and trauma-informed care to deal with superutilizers

4. Trauma-Informed Care Alicia Boccellari, Ph.D. Alicia Boccellari, Ph.D. is a Clinical Professor of Clinical Psychiatry and the Chief Psychologist in the UCSF Department of Psychiatry, Zuckerberg San Francisco General Hospital (ZSFG).  She is also the Director of the Trauma Recovery Center (TRC).  The TRC is designed to provide comprehensive mental health, case management and psychosocial services to survivors of violent crime.  In addition, Dr. Boccellari has been working with the California State Legislature to replicate the TRC evidence-based model of care in 10 other cities in California.  The UCSF TRC model is also currently being replicated in Ohio.

5. Impact of Trauma on Health Outcomes and High Risk Behaviors and the UCSF Trauma Recovery Center Model Alicia Boccellari, Ph.D. May 24, 2017 UCSFUniversity of California, San Francisco

6. Acknowledgements Slides adapted from: • San Francisco Department of Public Health Trauma Informed System of Care • Robert Anda, MD and Vincent Felleti, MD Kaiser Permanente and the Centers for Disease Control

7. WHAT IS TRAUMA? “Trauma is not an event in itself but, rather, a response to an experience that is so stressful that it overwhelms an individual’s capacity to cope”. Susan Craig (2008) Reaching and Teaching Children Who Hurt UCSF University of California, San Francisco

8. Trauma = Event, Experience, & Effect Actual or extreme threat of harm Event Experience Terror horror pain  Helpless to escape Fight / Flight - Freeze  Overwhelms brain and body Effect Dis-integration Dysregulation (Herman, 1997; Van der Kolk, 2005; DSM-IV-TR; SAMHSA; Siegel, 2012; Bloom, 2013) Lasting adverse effects SFDPH Trauma 101 Slide UCSF University of California, San Francisco

9. Fight, flight, freeze

10. Chronic Stress Causes “Wear and Tear” on the Body Medical illnesses Immune system suppression Inflammatory diseases Obesity Adverse effects on brain and cognitive functioning From stressors that are chronic, uncontrollable, experienced without support from caring others Can result from stressors like bigotry, poverty, chronic hunger (Bloom, 2013; McEwen, 2000) SFDPH Trauma 101 Slide UCSF University of California, San Francisco

11. Stress and Trauma Are Public Health Issues • Stress linked to 6 leading causes of death • Heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide • Trauma impacts more than just the individual • Ripple effect to others • Some communities disproportionately affected: • Bigotry + Urban Poverty + Trauma = Toxic • Intergenerational transmission of trauma • Systemic, preventative approach needed • SFDPH Trauma 101 Slide UCSF University of California, San Francisco

12. Let'stalkaboutAdverse Childhood Experiences: ACEs Felitti, Anda, et al. 1998 UCSF University of California, San Francisco

13. The Adverse Childhood Experiences (ACE) Study Examines the health and social effects of ACEs throughout the lifespan among 17,421 members of the Kaiser Health Plan in San Diego County What do we mean by Adverse Childhood Experiences? -childhood abuse and neglect -growing up with domestic violence, substance abuse or mental illness in the home, parental discord, crime Felitti, Anda, et al. 1998 UCSF University of California, San Francisco

14. AdverseChildhoodExperiencesAreCommon Household dysfunction: Abuse: UCSF University of California, San Francisco

15. AdverseChildhoodExperiencesScore • Numberofcategories(notevents)issummed… • ACEScorePrevalence • 0 33% • 1 25% • 2 15% • 3 10% • 4 6% • 5ormore11%* • TwooutofthreeexperiencedatleastonecategoryofACE. • IfanyoneACEispresent,thereisan87%chanceatleastone othercategoryof ACEispresent,and50%chanceof3or>. • * Womenare50%morelikelythanmentohaveaScore>5. UCSF University of California, San Francisco

16. UCSF University of California, San Francisco

17. HealthRisks ChildhoodExperiencesvs. AdultAlcoholism 4+ 3 2 1 1 0 UCSF University of California, San Francisco

18. UCSF University of California, San Francisco

19. Emotional costs Childhood Experiences Underlie Suicide Attempts 4+ 3 2 1 0 UCSF University of California, San Francisco

20. WithanACEScoreof0,the majorityofadultshavefew, ifany,riskfactorsforthesediseases. UCSF University of California, San Francisco

21. However, withanACEScoreof4ormore,themajorityofadultshave multipleriskfactorsforthese diseasesorthediseasesthemselves. UCSF University of California, San Francisco

22. Adverse Childhood Experiences Rarely Occur in Isolation… They come in groups. UCSF University of California, San Francisco

23. How does trauma affect the individual? Trauma shapes the survivor’s basic beliefs about themselves, others, their world view, spirituality. • Who am I? • The world is no longer safe • Others can’t be trusted • I have to protect myself no matter what • I can’t believe in anything now.

24. Basic capacities damaged by trauma: continued • Trust: • Inability to trust • Too trusting (can contribute to re-victimization)

25. Basic capacities damaged by trauma, continued: • Emotional extremes, difficulty modulating: • Intense affect • Hyper arousal, nightmares, flashbacks • Dissociation, self harm

26. Basic capacities damaged by trauma, continued: • Disrupted relationships, Boundary issues: • Hard to assess safe relationships • Reenact role (victim, perpetrator, bystander) • Difficulty w/ vulnerability & intimacy

27. How does trauma impact behavior •Inappropriate behaviors •Failures to connect cause and effect •Failure to understand directions •Perfectionism •“Overreacting” to comments or •Depression facial expressions •Anxiety •Hypervigilence •Self-destructive behaviors •Aggression •Fear and vulnerability •Feelings of worthlessness UCSF University of California, San Francisco

28. Prevalence: Trauma History Rates are higher in the population with severe mental illness (SMI) – 98% of SMI clients report at least one type of qualifying event in their lives. 51-97% of female SMI clients reporting sexual and or physical assault during their lifetime (Goodman, Rosenberg, Mueser, & Drake, 1997). Recent exposure: in a multi-site sample, approximately 1/3rd of SMI clients reported physical or sexual assault in the past year(Goodman, et al).

29. Patients served in public sector health care settings share additional risk factors: Lack of social support Adverse childhood experiences Low SES Limited education History of psychiatric disorder Kessler et al. (1995); Cottler et al (1992). PTSD Risk in Underserved Populations

30. Prevalence of the dual diagnosis of PTSD and Substance Abuse • Co-occurring diagnosis of PTSD and Substance Abuse in addiction treatment facilities - 12% - 34% • Women in substance treatment – 30% - 59% • Men in substance treatment – 11% - 38% Typically PTSD symptoms preceded the onset of substance abuse. Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford UCSF University of California, San Francisco

31. Links Between PTSD and Substance Abuse •Two main themes of both disorders are secrecy and control •Each of the disorders makes the other more likely •PTSD symptoms widely reported to become worse with initial abstinence •Both situations produce a profound need to be in an altered state Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford UCSF University of California, San Francisco

32. UCSF University of California, San Francisco

33. UCSF University of California, San Francisco

34. Trauma-Informed Approach Recognizes the widespread impact of trauma and understands potential paths for recovery; Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and Seeks to actively resist re-traumatization. SAMSHA UCSF University of California, San Francisco

35. Context •Trauma provides the context for behaviors •Move from: • What is wrong with you? • What has happened to you? SFDPH Trauma 101 Slide UCSF University of California, San Francisco

36. UCSF University of California, San Francisco

37. SAMHSA’s Six Key Principles of a Trauma-Informed Approach Safety Trustworthiness and Transparency Peer support Collaboration and mutuality Empowerment, voice and choice Cultural, Historical, and Gender Issues UCSF University of California, San Francisco

38. Traditional Psychotherapy for Trauma Victims • Office-based, no home visits • No practical assistance or coordination with other service systems • 50-minute hour • Feeling, insight, and disclosure-oriented

39. Vision: A New Model of Care • Emphasis upon assertive tracking, outreach, and engagement into services; AND • Clinical case management to address all basic needs (medical, legal, financial, housing, services etc.); AND • Evidence-based psychotherapy to target psychiatric distress and increase interpersonal safety

40. Engagement, Tracking & Outreach • Many victims feel ashamed about entering therapy and/or avoid trauma reminders. • We work with them on what is most important to them first until rapport is built. • We will see them at the hospital, at their home, or in their community (including homeless encampments, shelters, etc.).

41. Summary Results • 77% of survivors receiving TRC services engaged in mental health services when compared to 34% in customary care • Increased the rate by which sexual assault survivors received mental health services from 6% to 71% • 88% of clients reported an improvement in day-to-day functioning • 87% of clients reported an improvement in coping with alcohol and drug problems

42. Summary Results, continued: • PTSD symptoms decreased by 38% over 16 TRC sessions • Depression decreased by 52% over 16 TRC sessions • The TRC model costs 34% less than customary care

43. Lake County CIT Sgt. Keith Kaiser Keith Kaiser is a Sergeant with the Lake County Illinois Sheriff’s Office.  He has been a police officer for 16 years and has served in numerous positions throughout the Sheriff’s Office.  Keith obtained a Master of Science degree from Lewis University in Public Safety Administration.  Last November, Keith was appointed to the Sheriff’s position of Director of Training and Crisis Intervention Team Coordinator. 

44. Lake county sheriff’s office Crisis intervention team program Keith Kaiser

45. Lake County, Illinois Demographics • Northeast Corner of Illinois • Illinois 3rd largest county • Population ~ 700,000 • Sheriff’s Office serves ~ 130,000 • 445 square miles • Diverse Communities • Wealthy communities – Median Household Income ~ $150,000 • Underprivileged communities – Median Household Income ~ $38,000 • Veteran Population ~ 34,000 • Homeless Population ~ 300 (Point in Time Count) • County Poverty Rate ~ 9% • Sheriff’s Office ~ 580 Employees • ~ 200 Law Enforcement • ~ 200 Corrections Officers • 1,350 Law Enforcement Officers in Lake County

46. Lake County Sheriff’s OfficeCRISIS INTERVENTOIN TEAM PROGRAM CRISIS INTERVENTION & CRISIS INTERVENTION TEAM TRAINING

47. OUR PROBLEMS: National studies estimate 10% of law enforcement activities encounter persons with mental disorders. Lake County Sheriff’s Office ~20,000 encounters / year with persons with mental disorders. Incarceration: 15% have a serious mental disability (National Average) 41% recidivism rate within a 3 years period (Lake County Jail) CIT Program: 2005 – 16 Deputies - 4 Corrections Officers Trained 2014 – 4 Deputies - 1 Corrections Officer Trained The program was not utilized or implemented properly… “You don’t know what you don’t know.”

48. WHAT HAVE WE DONE? • County Board appropriated $30,0000 for CIT Training • Include municipal police in trainings • Implemented policies and procedures for CIT situations • A variety of employees are now CIT trained ~100 • Established partnerships with local organizations • Educated the community in regards to Crisis Intervention • JMHCP - $250,000 CIT Grant • Train 395 officers throughout the county • Track, evaluate, and follow-up with recipients of interventions • Familiarize officers with behavioral health resources and behavioral health providers

49. WHERE DO WE WANT TO BE… • Reduce the incarceration of mentally ill and provide them with positive interventions and connections • Track the identified Super Utilizers • Establish a local ILETSB certified CIT Training Host • Consistent CIT policies and procedures - county-wide • Integrate mental health providers and community members into the Crisis Intervention Team • Open two-way communication with providers • Develop a Mobile Response Team and Drop-In Centers • Establish community follow-up services: • Rides to treatment • Checks on truancy from appointments • Tracking and data evaluation - county-wide